Accurate assessment of the left atrial appendage (LAA) is important for pre-procedure planning when utilizing device closure for stroke reduction. Sizing is traditionally done with transesophageal echocardiography (TEE) but this is not always precise. Three-dimensional (3D) printing of the LAA may be more accurate. 24 patients underwent Watchman device (WD) implantation (71 ± 11 years, 42% female). All had complete 2-dimensional TEE. Fourteen also had cardiac computed tomography (CCT) with 3D printing to produce a latex model of the LAA for pre-procedure planning. Device implantation was unsuccessful in 2 cases (one with and one without a 3D model). The model correlated perfectly with implanted device size (R2 = 1; p < 0.001), while TEE-predicted size showed inferior correlation (R2 = 0.34; 95% CI 0.23–0.98, p = 0.03). Fisher’s exact test showed the model better predicted final WD size than TEE (100 vs. 60%, p = 0.02). Use of the model was associated with reduced procedure time (70 ± 20 vs. 107 ± 53 min, p = 0.03), anesthesia time (134 ± 31 vs. 182 ± 61 min, p = 0.03), and fluoroscopy time (11 ± 4 vs. 20 ± 13 min, p = 0.02). Absence of peri-device leak was also more likely when the model was used (92 vs. 56%, p = 0.04). There were trends towards reduced trans-septal puncture to catheter removal time (50 ± 20 vs. 73 ± 36 min, p = 0.07), number of device deployments (1.3 ± 0.5 vs. 2.0 ± 1.2, p = 0.08), and number of devices used (1.3 ± 0.5 vs. 1.9 ± 0.9, p = 0.07). Patient specific models of the LAA improve precision in closure device sizing. Use of the printed model allowed rapid and intuitive location of the best landing zone for the device.
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Atrial septal defect
Cardiac computed tomography
Glomerular filtration rate
Left atrial appendage
Left atrial appendage closure device
Patent foramen ovale
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Conflict of interest
Dr. Morris receives research support and is a consultant for Boston Scientific. All other authors have reported no relationships relevant to the contents of this paper to disclose.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board of the Einstein Healthcare Network and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Electronic supplementary material
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Video 1 Three-dimensional transesophageal echocardiography (TEE) clips from the left atrial appendage (LAA) depicted in Fig. 2. The LAA appendage orifice is partially obscured by the “Coumadin ridge”. In this patient standard two-dimensional TEE views underestimated the true orifice size. (MP4 976 KB)
Video 4 Two-dimensional transesophageal (TEE) image at 0 degrees for the left atrial appendage (LAA) depicted in Fig. 3. Imaging was difficult and it can be appreciated that the views obtained are off-axis and likely not through the center of the LAA (similarly in Videos 5 to 7). In addition, probe position was higher in the esophagus than is optimal for LAA imaging (as evidenced by the appearance of both the aortic and pulmonic valves in this image). In fact, TEE underestimated the size of device required for this patient. (AVI 5067 KB)
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Obasare, E., Mainigi, S.K., Morris, D.L. et al. CT based 3D printing is superior to transesophageal echocardiography for pre-procedure planning in left atrial appendage device closure. Int J Cardiovasc Imaging 34, 821–831 (2018) doi:10.1007/s10554-017-1289-6
- Left atrial appendage
- Left atrial appendage closure device
- Three-dimensional printing
- Multi-modality imaging
- Atrial fibrillation